title: Sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute pulmonary embolism in PIOPED II.
abstract: We used the archived Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) data and images to test the hypothesis that reading perfusion scans with chest radiographs but without ventilation scans, and categorizing the perfusion scan as "pulmonary embolism (PE) present" or "PE absent," can result in clinically useful sensitivity and specificity in most patients.
  
  
  METHODS
  Patients recruited into PIOPED II were eligible for the present study if they had a CT angiography (CTA) or digital subtraction angiography (DSA) diagnosis, an interpretable perfusion scan and chest radiographs, and a Wells' score. Four readers reinterpreted the perfusion scans and chest radiographs of eligible patients. Two readers used the modified PIOPED II criteria and 2 used the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria. The chest radiographs were read as "normal/near normal," "abnormal," or "nondiagnostic," and the perfusion scans were read as "PE present," "PE absent," or "nondiagnostic." The primary analysis used a composite reference standard: the PIOPED II DSA result or, if there was no definitive DSA result, CTA results that were concordant with the Wells' score as defined in PIOPED II (CTA positive and Wells' score > 2, or CTA negative and Wells' score < 6).
  
  
  RESULTS
  The prevalence of PE in the sample was 169 of 889 (19%). Using the modified PIOPED II criteria, the sensitivity of a "PE present" perfusion scan was 84.9% (95% confidence interval [CI], 80.1%-88.8%), and the specificity of "PE absent" was 92.7% (95% CI, 91.1%-94.1%), excluding "nondiagnostic" results, which occurred in 20.6% (95% CI, 18.8%-22.5%). Using PISAPED criteria, the sensitivity of a "PE present" perfusion scan was 80.4% (95% CI, 75.9%-84.3%) and the specificity of "PE absent" was 96.6% (95% CI, 95.5%-97.4%), whereas the proportion of patients with "nondiagnostic" scans was 0% (95% CI, 0.0%-0.2%).
  
  
  CONCLUSIONS
  Perfusion scintigraphy combined with chest radiography can provide diagnostic accuracy similar to both CTA and ventilation-perfusion scintigraphy, at lower cost and with lower radiation dose. With modified PIOPED II criteria, a higher proportion of scans were nondiagnostic than with CTA, and with PISAPED criteria none were nondiagnostic.
authors.affiliation: Office of the Dean and Department of Radiology, Weill Cornell Medical College and Methodist Hospital, Houston, Texas 77030, USA. dsostman@tmhs.org
authors.forename: H Dirk
authors.initials: HD
authors.lastname: Sostman
authors.forename: Massimo
authors.initials: M
authors.lastname: Miniati
authors.forename: Alexander
authors.initials: A
authors.lastname: Gottschalk
authors.forename: Fadi
authors.initials: F
authors.lastname: Matta
authors.forename: Paul D
authors.initials: PD
authors.lastname: Stein
authors.forename: Massimo
authors.initials: M
authors.lastname: Pistolesi
mesh_terms: D000208:Acute Disease; D006801:Humans; D055420:Perfusion Imaging / Q000379:methods*; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000000981:diagnostic imaging; D013902:Radiography, Thoracic / Q000379:methods*; D012680:Sensitivity and Specificity